You Be the Coder:
To Append an Attempt or Not
Published on Sat Mar 01, 2003
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I bill for an unsuccessful attempt of a procedure? My otolaryngologist attempted 69210, but the child screamed and cried so much that the mother asked the physician to stop. The visit was only for scheduled routine cerumen removal because the boy's hearing aids cause impacted cerumen. Should I use a modifier or some other code to signify to the insurance company that the doctor attempted the procedure but was unsuccessful? Colorado Subscriber
Answer: In certain circumstances, otolaryngologists may find it necessary to alter or discontinue a procedure at the physician's discretion or because of unanticipated risk to the patient. When this occurs, you should use a modifier to inform the payer that a defined service was attempted but was altered by specific circumstances. You will commonly use two modifiers in these situations. Modifier -52 (Reduced services)indicates that a physician partially reduced or eliminated part of a procedure at his or her discretion, according to CPT 2003 Appendix A. Modifier -53 (Discontinued procedure) identifies a procedure that the doctor terminates due to circumstances that create risk for the patient. In the situation you describe, the otolaryngologist attempted the procedure, but the patient's guardian requested that the physician discontinue the removal. Consequently, you should report 69210 (Removal impacted cerumen [separate procedure], one or both ears) appended with modifier -53 to indicate that the doctor discontinued the procedure due to patient elect. In contrast, if the otolaryngologist chose to perform only part of a procedure and the CPT code describes a larger service, you would append modifier -52 to the procedure code. For instance, a child complains of hearing loss in the right ear only, so he instructs the audiologist to test that ear only. In this case, you would assign 92552-52 (Pure tone audiometry [threshold]; air only). When submitting claims containing modifier -52 or -53, the otolaryngologist should document when and why he or she reduced or discontinued the service. Explain the exact circumstances that led to the decision to reduce or terminate the procedure. Send a cover letter and the chart note with the claim so the payer can make an informed decision concerning how to adequately price the level and extent of service you provided. Bill the study at full fee, send in the claim with documentation and let the payer determine the fee.
